Healthcare Provider Details

I. General information

NPI: 1922683408
Provider Name (Legal Business Name): MARQUISE GREGORY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 S LAFAYETTE ST
SHELBY NC
28152-6658
US

IV. Provider business mailing address

PO BOX 749
BELMONT NC
28012-0749
US

V. Phone/Fax

Practice location:
  • Phone: 980-484-3390
  • Fax: 980-842-0212
Mailing address:
  • Phone: 704-869-2088
  • Fax: 980-288-4239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49968
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number3705
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: